A Delay In Relief From Copays For Costly Drugs

Expensive prescriptions drugs can stretch people's finances, even if they have insurance.

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For people with a chronic or serious illness, drugs that can help slow or cure the disease often put a financial strain on even the best insurance coverage.

The Affordable Care Act sets annual limits on the amount that people will owe out of pocket for prescription drugs starting in 2014. But sick people in some plans won't get relief until the following year because the federal government is giving some health plans extra time to comply.

"People living with multiple sclerosis and other chronic illnesses have been counting on this annual out-of-pocket limit coming, and now that may not happen in 2014," says Bari Talente, executive vice president of advocacy at the National Multiple Sclerosis Society.

Drugs to treat multiple sclerosis are frequently on an insurer's specialty drug tier and require a person to pay 25 to 30 percent of the cost rather than a fixed copayment, she says. In such cases, someone might spend roughly $700 out of pocket every month — $8,400 a year — on a drug to slow progression of the disease.

Under the law, the maximum amount that a consumer with single coverage will pay out of pocket for all medical care, including drugs, will generally be $6,350 in 2014. A family could pay as much as $12,700.

Those totals include copayments, coinsurance and deductibles, but not premiums, and they apply only to plans that are not grandfathered under the law.

But for those consumers whose health plans use more than one administrator to manage plan benefits — one for major medical claims and coverage, and another for pharmacy, for example — there may be one out-of-pocket cap for major medical and another for drugs, or no drug spending limits at all if a plan doesn't currently have a cap, as is typical.

The administration said in February that it recognized that the new annual out-of-pocket limits would need to be coordinated and might require new communication between service providers. That communication step is the reason the government gave the health plans extra time to comply.

But what's good for health plans isn't necessarily good for patients. "For those who are going to be hit with a double out-of-pocket maximum, it could be problematic," Talente says.